Risk of eating disorders in a representative sample of Italian adolescents: prevalence and association with self-reported interpersonal factors

Behind the mirror: An exploration of the Tripartite Influence Model among Italian adolescent boys and girls

Body image concerns and eating disorder (ED) symptoms are increasingly common among adolescents, highlighting the importance of discerning their risk factors. One of the main frameworks explaining the development of body image and eating-related issues is the Tripartite Influence Model (TIM); however, adolescent research examining this model remains scarce and mainly limited to female individuals. Therefore, this study aimed to test the original TIM in a sample of 788 Italian students (59 % girls) aged 13-19 years. They completed self-report tools assessing appearance-related sociocultural pressures, general attractiveness-ideal internalization, appearance comparison frequency, body shame, and ED symptoms. Path analysis was employed to test the TIM in the overall sample, followed by a multigroup analysis by biological sex. The results showed that, in both groups, family pressure was linked to body shame directly and to ED symptoms via body shame; however, neither internalization nor appearance comparisons mediated these relations. Peer pressure was associated with body shame via appearance comparisons but not via internalization. Media pressure was related to body shame both directly and via appearance comparisons and indirectly linked to ED symptoms through body shame. In girls, significant relations between family pressure and ED symptoms, as well as between media pressure and internalization, also emerged. The practical implications are discussed, especially regarding culturally sensitive prevention programs.

Italian adolescents' body image and sociocultural influences: An investigation using the Sociocultural Attitudes Towards Appearance Questionnaire-4-Revised

Body dissatisfaction and eating disorders (EDs) are highly prevalent among adolescents, imposing a significant burden on this group. Therefore, a deeper investigation into the risk factors of these issues is urgently needed. In this regard, adopting a sociocultural framework can offer valuable insights; however, research on the assessment of appearance-related sociocultural pressures among adolescents remains limited. This study aimed to validate the Sociocultural Attitude Towards Appearance Questionnaire-4-Revised (SATAQ-4R) among Italian adolescents aged 13-17 years. A total of 692 girls (Mage = 15.5 years ± 1.16) and 450 boys (Mage = 15.2 years ± 1.21) completed the Female and Male versions of the SATAQ-4R along with other self-report tools assessing ED symptoms, body dissatisfaction, self-esteem, peer and family appearance pressure, drive for muscularity, and frequency of Instagram appearance comparisons. To investigate the SATAQ-4R factor structure, several models were tested. Measurement invariance across early and middle adolescent groups, reliability, and validity were addressed. The original 7-factor model yielded the best fit to the data for both boys and girls. This model was also invariant across age groups. Both the SATAQ-4R-Male and Female exhibited excellent psychometric properties in terms of construct and criterion validity, as well as internal consistency (McDonald's omega values ranging from .79 to .93 for the SARAQ-4R-Male and from .82 to .93 for the SATAQ-4R-Female). Therefore, the SATAQ-4R can be considered a valid and reliable tool for measuring societal influences on body image among Italian adolescents. Research and practical implications are discussed.

The role of perceived parental overprotection in women's restrained eating behavior: A moderated mediation model of alexithymia, perfectionism, and asceticism

Restrained eating behavior (REB) refers to the tendency to rigidly restrict one's eating behavior in everyday life to influence body shape or weight. Parental overprotection, alexithymia, perfectionism, and asceticism are associated with REB among women. However, no studies have examined these variables simultaneously, integrating them into a theoretical model. In the current study, the combined influences of these variables on women's REB were tested. A total of 412 women (Mage = 23.53 ± 4.24; range = 16-54) completed well-known self-report measures: Parental Bonding Instrument, Toronto Alexithymia Scale, Multidimensional Perfectionism Scale, Protestant Work Ethic Scale, and Eating Disorder Examination Questionnaire. Parallel mediation and moderated mediation hypotheses were tested using PROCESS Model 4 and PROCESS Model 15, respectively. The paths from both maternal and paternal overprotection to REB were mediated through alexithymia and socially prescribed perfectionism. There was a significant interaction effect of asceticism with socially prescribed perfectionism on REB in the model concerning paternal overprotection (b = 0.0185, SE = 0.0091, 95% CI = 0.0007-0.0363). Moreover, asceticism significantly moderated the effect of paternal overprotection on REB through socially prescribed perfectionism (b = 0.0032, SE = 0.0019, 95% CI = 0.0001-0.0076). For the model concerning maternal overprotection, the moderated mediation model was not supported. The findings support a theoretical model of risk factors for REB and highlight the possible mechanisms through which the quality of early parental relationships contributes to REB.

Translation and Adaptation of the SCOFF Questionnaire to the Greek Language (G-SCOFF) Using a Tertiary-Setting Adolescent Sample

BACKGROUND/OBJECTIVES

Feeding and eating disorders (FEDs) constitute an important mental health problem today, especially among youngsters. The Sick, Control, One, Fat, Food (SCOFF) questionnaire was developed 25 years ago and remains the most frequently applied screening tool for FEDs among adults and youngsters. The aim of the present study was to translate and adapt the SCOFF questionnaire to the Greek language, using a tertiary-setting adolescent sample.

METHODS

A total of 167 adolescents (86 boys, 81 girls) admitted to the pediatric outpatient clinics of the Georgios Gennimatas and Hippokration General hospitals completed the SCOFF questionnaire. Anthropometric indices were measured and dietary intake was recorded.

RESULTS

A total of 74 adolescents (44.3% of the sample) were classified as engaging in disordered eating behaviors and as possible patients with FEDs based on the SCOFF questionnaire. No differences were noted in the dietary intake between adolescents who screened positive and those who screened negative for FEDs. The body mass index z-score and obesity status were greater among children screening positive for FEDs compared to those screening negative (p < 0.01). One patient who was later diagnosed with anorexia nervosa was detected as a possible FED case by the questionnaire.

CONCLUSIONS

The present study revealed that more than two out of five adolescents attending a pediatric clinic exhibited disordered eating behavior. The use of the G-SCOFF questionnaire is feasible and effective for FED triage in the Greek tertiary pediatric setting.

A Longitudinal Study on Body Image Perception and Size among Italian Early Adolescents: Changes over Time and Discrepancies between Genders

BACKGROUND/OBJECTIVES

The discrepancy between the current perceived body image (BI) and beauty ideals leads to dissatisfaction, which is believed to be common among adolescents. This study aimed to investigate the stability in BI perceptions and dissatisfaction during early adolescence. Another aim was to highlight differences in dissatisfaction according to Body Mass Index (BMI) and inconsistencies in weight status perception.

METHODS

Two hundred and nine participants (mean age at first survey: 11.33 ± 0.38 years) were enrolled in this longitudinal study with three years of follow-up. Data on size and BI perceptions were collected through individual interviews. Stature and weight were directly measured.

RESULTS

Findings indicated significant changes over three years in anthropometric traits but not in weight status prevalence or BI perception and dissatisfaction, except for the ideal figure in males and weight control in females. The results also indicated a significant difference in BI perception and dissatisfaction by BMI categories. Self-reported body measurements were found to be unreliable with a weak-to-moderate agreement between self-perceived and actual weight status.

CONCLUSIONS

BI perception appears quite stable across the three years considered. Dissatisfaction is similar in both genders, although a tendency toward different gender aesthetic ideals is already appreciable in early adolescence. We suggest that the lower frequency of normal-weight adolescents compared with peers in previous studies is attributable to the effects of the recent pandemic. Given the growing dissatisfaction with increasing BMI and misinterpretations of weight status, school actions to promote a healthy lifestyle and positive BI should be undertaken.

Association of Dietary Habits with Eating Disorders among Latvian Youth Aged 18-24

Eating disorders are serious health issues among young people that contribute to increased morbidity rates. The prevalence and severity of eating disorders among Latvian youth aged 18-24 and their relationship with the Healthy Eating Index, dietary habits, and BMI were analyzed in the present study. At the beginning of the study, 190 respondents participated by completing the SCOFF questionnaire, from which the sample group was selected based on the criterion of SCOFF ≥ 2. For the next stage of the study, the responses of 74 participants who completed the EDE-Q-6 questionnaire and the Canadian Food Intake Screener were analyzed. The symptoms of eating disorders were identified in 38.9% of the respondents (SCOFF ≥ 2). The global score of the EDE-Q-6 was 2.00 ± 1.81 where subscales such as body shape concerns (2.93 ± 1.44) and weight concerns (2.68 ± 1.36) were the most important factors that young people paid attention to. The severity of eating disorders was 3.20 for males and 2.62 for females, where a score of 4 and above is classified as an eating disorder. Participants with eating disorder symptoms had a higher BMI, with females having a BMI of 22.5 (normal weight) and 25.5 for males (overweight). The study sample had a poor diet, as the Healthy Eating Index was 8.7 with a maximum score of 24. Weak negative correlations were found between eating disorder severity and eating habits. The issue of eating disorders is topical among young people in Latvia, which requires solutions such as the inclusion of educational programs on healthy nutrition and eating disorders, and psychological support for young people.

The use and misuse of the SCOFF screening measure over two decades: a systematic literature review

PURPOSE

The SCOFF questionnaire was designed as a simple, memorable screening tool to raise suspicion that a person might have an eating disorder. It is over 20 years since the creation of the SCOFF, during which time it has been widely used. Considering this, we wish to review the use of the SCOFF in peer-reviewed scientific journals, and to assess whether it is being used appropriately in the manner in which it was originally devised and tested.

METHODS

The Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were followed, and all search strategies and methods were determined before the onset of the study. PubMed and Wiley Online Library were searched using the terms SCOFF and eating. Two reviewers were involved in the reviewing process. Criteria for appropriate use of the SCOFF were formalised with the tool's original authors.

RESULTS

180 articles were included in the final review. 48 articles had used the SCOFF appropriately, 117 articles inappropriately and 15 articles had been mixed in the appropriateness of their use.

CONCLUSION

This systematic review highlights the inappropriate use of the SCOFF in diverse languages and settings. When used correctly the SCOFF has made a significant contribution to the understanding of eating disorders and its simplicity has been applauded and led to widespread use. However in over two-thirds of studies, the use of the SCOFF was inappropriate and the paper highlights how and in what way it was misused, Guidelines for the appropriate use of the SCOFF are stated. Future validation and avenues of research are suggested.

LEVEL OF EVIDENCE

Level I.

Food and Alcohol Disturbance in High School Adolescents: Prevalence, Characteristics and Association with Problem Drinking and Eating Disorders

Food and alcohol disturbance (FAD) is characterized by the association of alcohol use with compensatory behaviors such as restricting calories, physical activity and purging. Despite not being part of the current nosography, research has grown in the past 10 years, mostly on college students' samples. In this study, we aim to describe the prevalence, characteristics and association of FAD with problem drinking (PD) and eating disorder risk (EDR) in a sample of Italian high school students. Participants were 900 high school students (53.6% males; mean age = 16.22) that were administered standardized questionnaires. Students who screened positive for PD, EDR and both were, respectively, 17.3%, 5.9% and 1.3%. Approximately one out four students reported FAD behaviors, mostly to control weight and by restricting calories, with higher prevalence and severity among those who screened positive for PD. Purging behaviors were rare overall (15.5%), but significantly more frequent in participants who screened positive for both PD and EDR (41.7%). FAD was more strongly associated with alcohol use severity than with ED symptom severity across all subgroups. FAD behaviors appear to be common in the Italian high school population and more strongly associated with PD. Future studies should investigate FAD's impact on adolescents' functioning and possible early interventions.

The association between sport type and eating/body image concerns in high school students: a cross-sectional observational study

PURPOSE

Disordered eating and body image concerns are increasingly common among adolescents, possibly representing the underpinning of eating disorders (EDs). This cross-sectional observational study aimed at investigating the relationship between various patterns of sports involvement or inactivity, and the abovementioned psychopathological dimensions.

METHODS

All adolescents attending their 3rd-5th Italian grade in a single high school reported their sociodemographic and anthropometric data, their weekly sports involvement, and filled the Eating Disorders Examination Questionnaire 6.0 (EDE-Q), the Body Uneasiness Test, and the Muscle Dysmorphia Disorder Inventory (for boys). Comparisons were performed considering sex, weekly hours of activity, and different sports type (none, individual, or team sports).

RESULTS

Of 744 enrolled students, 522 (70.2%) completed the survey. Girls showed higher underweight rates, preference for inactivity or individual sports, and higher psychometric scores compared to boys. Among girls, no differences were found based on time spent exercising or sports type. Inactive boys displayed worse weight- and shape-based psychopathology, higher body uneasiness, and higher appearance intolerance compared to those who devoted more time to exercise. Among boys, individual and team sports were associated with lower EDE-Q scores compared to inactivity, whereas body uneasiness and appearance intolerance were lower only in team sports.

CONCLUSIONS

The study confirms the presence of remarkable sex differences in eating and body concerns of adolescents. Among boys, sports involvement is tied to lower ED psychopathology, and preference for team sports may be associated with reduced concerns. Wider longitudinal studies on will clarify the direction and specificity of these findings.

LEVEL OF EVIDENCE

Level V-Cross-sectional observational study.

Global Proportion of Disordered Eating in Children and Adolescents: A Systematic Review and Meta-analysis

Importance

The 5-item Sick, Control, One, Fat, Food (SCOFF) questionnaire is the most widely used screening measure for eating disorders. However, no previous systematic review and meta-analysis determined the proportion of disordered eating among children and adolescents.

Objective

To establish the proportion among children and adolescents of disordered eating as assessed with the SCOFF tool.

Data Sources

Four databases were systematically searched (PubMed, Scopus, Web of Science, and the Cochrane Library) with date limits from January 1999 to November 2022.

Study Selection

Studies were required to meet the following criteria: (1) participants: studies of community samples of children and adolescents aged 6 to 18 years and (2) outcome: disordered eating assessed by the SCOFF questionnaire. The exclusion criteria included (1) studies conducted with young people who had a diagnosis of physical or mental disorders; (2) studies that were published before 1999 because the SCOFF questionnaire was designed in that year; (3) studies in which data were collected during COVID-19 because they could introduce selection bias; (4) studies based on data from the same surveys/studies to avoid duplication; and (5) systematic reviews and/or meta-analyses and qualitative and case studies.

Data Extraction and Synthesis

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

Main Outcomes and Measures

Proportion of disordered eating among children and adolescents assessed with the SCOFF tool.

Results

Thirty-two studies, including 63 181 participants, from 16 countries were included in this systematic review and meta-analysis. The overall proportion of children and adolescents with disordered eating was 22.36% (95% CI, 18.84%-26.09%; P < .001; n = 63 181) (I2 = 98.58%). Girls were significantly more likely to report disordered eating (30.03%; 95% CI, 25.61%-34.65%; n = 27 548) than boys (16.98%; 95% CI, 13.46%-20.81%; n = 26 170) (P < .001). Disordered eating became more elevated with increasing age (B, 0.03; 95% CI, 0-0.06; P = .049) and body mass index (B, 0.03; 95% CI, 0.01-0.05; P < .001).

Conclusions and Relevance

In this systematic review and meta-analysis, the available evidence from 32 studies comprising large samples from 16 countries showed that 22% of children and adolescents showed disordered eating according to the SCOFF tool. Proportion of disordered eating was further elevated among girls, as well as with increasing age and body mass index. These high figures are concerning from a public health perspective and highlight the need to implement strategies for preventing eating disorders.

Prevalence of Disordered Eating and Its Associated Factors From a Socioecological Approach Among a Sample of Spanish Adolescents: The EHDLA Study

Objectives: The aim of this study was twofold: a) to establish the prevalence of adolescents with disordered eating and b) to determine the factors associated with this prevalence in a sample of Spanish adolescents from the Valle de Ricote (Region of Murcia, Spain).

Methods: This cross-sectional study analyzed data from 730 adolescents (56.2% girls) from the EHDLA study. To determine the prevalence of disordered eating, the Sick, Control, One stone, Fat, Food (SCOFF) questionnaire was used. A socioecological approach was used to identify individual-, interpersonal-, or organizational-level factors associated with disordered eating.

Results: The prevalence of disordered eating was 30.1%. This condition was associated with female sex (odds ratio [OR] = 2.60; 95% confidence interval [CI], 1.81–3.73), immigrant status (OR = 2.22; 95% CI, 1.51–3.25), or excess weight (OR = 2.74; 95% CI, 1.93–3.89). Furthermore, for each additional hour slept, lower odds of having disordered eating were found (OR = 0.81; 95% CI, 0.67–0.98).

Discussion: Almost one-third of the sample of Spanish adolescents analyzed reported disordered eating. Female sex, immigrant status and excess weight are individual aspects that seem to be related to disordered eating among Spanish adolescents.

Associations between sex differences, eating disorder behaviors, physical and mental health, and self-harm among Chinese adolescents

BACKGROUND AND AIM

Eating Disorders (ED) result in impaired well-being, but there exist an insufficient number of studies that have focused on the influence of sex and sexual orientation disparities within ED behaviors. Thus, we aimed to investigate ED behaviors among male and female adolescents with different sexual orientations in a school sample to understand prevalence and correlates of different ED behaviors.

METHOD

Data was analysed from 11,440 Chinese school adolescents with a mean age of 14.74 years (SD = 1.46). Reported data was gathered on sociodemographic information including sexual orientation, ED behaviors, health factors (reported health, cognitive function), mental health factors (depression, anxiety, suicidal ideation, non-suicidal self-injurious behavior), and social functioning (school bully victimization, and school bully perpetration). Logistic regression models were used to estimate the associations with ED behaviors, using the heterosexual orientation as the reference group as they are the majority.

RESULTS

Compared to female adolescents, male adolescents reported lower anxiety symptoms (t = - 12.39, p < 0.001, Cohen's d = - 0.233), were more likely to be the perpetrator of school bullying (χ² = 190.61, p < 0.001, φ = 0.129), and reported a lower likelihood of taking dietary restriction (χ² = 290.08, p < 0.001, φ = 0.160). Overall, the prevalence of dietary restriction presented sex disparities. Adolescents who reported no sexual attraction were less likely to engage in ED behaviors. Using heterosexual orientation as the reference group, the group who reported no sexual attraction was associated with lower risk in dietary restriction and purging in both male and female adolescents. Using the heterosexual orientation as the reference group, female sexual minority groups were at high risk of ED behaviors, with bisexual orientation and gay/lesbian orientation having a higher likelihood of engaging in objective binge eating.

CONCLUSIONS

The results revealed significant sex and sexual orientation differences of ED behaviors. The study suggests that adolescents is a period of sexuality development and could be critical for understanding adolescents' eating behaviors. It is important to guide adolescents to healthy eating during their development and considerations should be made by clinicians when creating interventions for ED behaviors among the different sex and sexual orientation groups.

Body Image Perception in High School Students: The Relationship with Gender, Weight Status, and Physical Activity

Body image perception includes body size assessment, body desirability estimation, and perceptions concerning one’s own body shape and size. Adolescence is a period of intense and prompt physical transformation, which changes the perception of one’s body. This represents a critical period for the development of body image. Therefore, the present cross-sectional study aimed to evaluate body image perception and investigate the relationships between it, weight status, sex, and physical activity in a sample of high school students living in Italy. General demographic information and details about physical activity were collected. Body image perception was measured with a body silhouette and two indexes were calculated: the FID (Feel minus Ideal Discrepancy) to evaluate the discrepancy between the perceived current figure and the ideal figure; and the FAI (Feel weight status minus Actual weight status Inconsistency) to observe improper perception of weight status. In addition, body shape concerns were evaluated with the Body Shape Questionnaire (BSQ), in which participants reported the frequency of experiencing negative thoughts about their body shape in the last four weeks. Two hundred and four students were included in the study (155 = female, mean age = 17.13 ± 1.70; 49 = male, mean age = 17.25 ± 1.69). Females felt more concerned about body shape than males (χ2 = 11.347, p = 0.001). Distinctions emerged in terms of body mass index, the scores of Feel minus Ideal Discrepancy (FID), Feel weight status minus Actual weight status Inconsistency (FAI), the Body Shape Questionnaire (BSQ), and of the silhouette mean comparisons due to sex, weight status, and PA interaction effects (p < 0.001). Additionally, 94% of the BSQ variability could be explained by sex, weight status, and PA. Although no direct effects were observed on body image perception, healthy habit promotion, such as physical activity, could positively affect adolescent lives.